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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 1077 - 8th August Posted By: Admin_Dermpath

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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M65. Biopsy ankle. Chronic liver disease. ?Bullous dermatosis

Case Posted by Dr Richard Carr


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Arti Bakshi

Posted

Hmm..difficult.
The most striking feature is the confluent parakeratosis. This coupled with tortuous capillaries in the papillary dermis and increased basal mitoses, initially made me think of psoriasis, but there are no neutrophils. (plus clinical does not fit)
So would consider a nutritional deficiency, perhaps on a background of chronic liver disease.

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There´s some patients with chronic liver disease mostly by viral hepatitis C infection who develops sacaly plaques over dorsal acral surfaces. I think this patient has Necrolytic acral erythema.
The histological pictures are very similar to other nutritional disorders like Necrolitic migratory erythema and Pelagra.

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Robledo F. Rocha

Posted

Agree with nutritional deficiency. There´s neither inflammatory infiltrate nor regular epidermal hyperplasia for psoriasis. Also, confluent parakeratosis is a clue for nutritional deficiency.
Suggesting another diagnostic hypothesis, glucagonoma syndrome, which may be associated to advanced liver cirrhosis, may present as necrolytic migratory erythema with microscopic features like those shown in the pictures above.

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Arti Bakshi

Posted

Like Igor's suggestion of necrolytic acral erythema, would fit with the clinical. Important to know hep C status.

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Dr. Mona Abdel-Halim

Posted

Fits with necrolytic acral erythema

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Based on clinical history consistent with necrolytic acral erythema

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Based on clinical history consistent with necrolytic acral erythema

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Guest Romualdo

Posted

Agree with necrolytic acral erythema.

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Dr. Richard Carr

Posted

The initial reporting pathologist called this bowen's disease. The clinical colleagues had queried nutritional deficiency and tested the Zinc levels which were very low. The diagnosis was therefore nutritional deficiency dermatosis due to low zinc (acrodermatitis enteropathica). I have not personally seen a case of necrolytic acal erythema in the UK either personally or for that matter presented at any meeting although I understand that some (but not all) cases are associated with low zinc levels. For completeness I will try to enquire about the nature of the underlying liver disease although this case is a from a few years ago and was shared with me by a colleague at another institute.
Enjoy the rest of your weekends.

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Mark A. Hurt MD

Posted

It is written that epidermal pallor is a clue to zinc deficiency, but I have seen two cases of it that lack that finding. These can be found as follows: http://www.ncbi.nlm.nih.gov/pubmed/18537855

This is clearly not Bowen's disease.

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